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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCJIKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT HAME <br /> F p <br /> A 1Y/ >i-C / lGr Mi'vt C'� aA <br /> I FACILITY ADDRESS SITE PHONE with AREA C <br /> I <br /> T CITY � STATE ZIP CCO 4 of TANKS <br /> T J G-l�- ✓t �-3 C�S�V ' at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME ! <br /> P <br /> L <br /> 1 MAILING ADDRESS /1 - APPLICANT PHONE 7 WITH AREA CODE <br /> A <br /> N CITY STATE ZIP =1 TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> z0(Ah 1eI TOTAL <br /> A <br /> C 1986 1987 I 1988 1 1989 1 1990 <br /> T ANNUAL FACILITY FEE CPrior to January 1, 191) _ iDO e <br /> doo JdOP I dool 2 s-oo «: <br /> TANK FEE - 550.00/TAHK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> 1996 <br /> anks <br /> A ply 7Ts/-fee for 1986 1987 1988 1989 1990 t991 1992 1995 1994 1995 <br /> C each year applicable) <br /> t r%jSJ �' <br /> �� O io <br /> LSTATE SURCHARGE - 556.00 each TANK (Due every 5 years) See California H 7. S Code, Section 25257 <br /> I <br /> T I Al Tanks, x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) C <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptaee) I TANK I.D. Y(s) <br /> C <br /> L CLOSURE FEE - 553.00 per hour (3 hours minimum per TANK) / TANK(s)_ X 2159.00 = S <br /> 0 <br /> S <br /> U TEMPCRARY CLOSURE (A one-time permit, for review/inspeetiane) TANK I.D. N(a) <br /> R <br /> E TEMPCRARY CLOSURE FEE - 5150.00 each TANK 4 TANK(S) X $150.00 = 2 <br /> P PLAN CHECK (Install. Plan Review i Construction Inspections) TANK I.D. f(s) <br /> L <br /> A <br /> 4 PLAN CHECK FEE - 553.00 per hour (8 hours mining per Facility) • 5424.00 miniuua S <br /> R REPAIR FEE (workplan review L constructim impectiorss) TANK I.D. S(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimuWTANK) 9 TANK(s) _ X $159.00 S <br /> A <br /> I <br /> R PIPING REPAIR FEE • 253.00 per hour (3 hour minimus per facility - 2159.00) S <br /> M TRANSFER FEE • 220.00 UNAUTHORIZED RELEASE EVALUATION = 253.00/hr S <br /> I <br /> S <br /> C I CCNSOLTATICN FEE = 553.001hr I SAMPLING INSPECTION FEE = 553.00/hr S___� <br /> TOTAL S <br /> OFFICE USE ONLY <br /> lR_l <br /> r s I� ac---- _•-�fw[�rsi�a -- pfd --- ----a-[�-•�-ea l�a� <br /> cr$= Ui cR i Lv�L t �J�?MI .Wla. �C: <br /> i <br /> f <br />